Health issues are both a cause and effect of homelessness.
MediaNews Group via Getty Images
My first job in health care was at the Harvard Square Homeless Shelter, where I helped launch a clinic to provide medical care to people experiencing homelessness. It was in that setting that I met a patient I’ll called “Fred.” Fred had complex health issues including substance abuse problems and chronic diseases — the kinds of comorbidities that require intense coordination.
But that’s not at all what Fred got from the health care system. Our fee-for-service system of care isn’t designed to provide that level of coordination. I remember, during a particularly frigid Boston winter, Fred got frostbite. He went to a local ER, where doctors performed surgery on his hands…and sent him right back out into the cold.
Needless to say, when I met Fred he didn’t have a lot of trust in doctors or the health system in general. Like so many other services he received, health care was fragmented and didn’t do much to help Fred with the underlying conditions that kept him out on the streets.
Today, the number of people experiencing homelessness in America is staggering. According to the U.S. Census Bureau, more than 550,000 people experienced homelessness on any given day in 2018. We often think of homelessness as a housing issue. But the same conditions prevail today that inspired me to launch that clinic during my undergraduate days: homelessness is both a recognized cause and a result of health problems.
Which is why we need a new approach to it.
Together with John Baackes of LA Care and Jim O’Connell of Boston Healthcare for the Homeless, I recently proposed the creation of a homelessness-focused Medicare Advantage special needs plan. Special needs plans are insurance plans aimed at meeting the unique care needs of specific high-need populations. We believe this could be an approach through which to sustainably finance a better system of health care delivery for homeless individuals.
Special Needs Plans
Special needs plans, first authorized by Congress in the Medicare Modernization Act of 2003, are Medicare Advantage plans that may limit enrollment to defined groups of Medicare beneficiaries. Diabetes special needs plans, for example, offer specialized benefits, physician choices, and drug formularies to optimize care for individuals with diabetes; institutional special needs plans focus on the specific care needs of patients who live in assisted living or nursing home facilities. Research indicates that some special needs plans have successfully led to reductions in emergency department use and hospital admissions and readmissions.
The Homeless Special Needs Plan
As was the case with Fred, homeless individuals enrolled in traditional fee-for-service Medicare plans are often underserved by a delivery system that’s focused on addressing the effects of homelessness, not the related underlying mental health, substance use, or economic or social conditions that cause it; this care is expensive and suboptimal.
But a homeless special needs plan would partner with medical groups, social services agencies, community organizations, housing providers and others who provide services for homeless individuals. Efforts would be tailored to support medical care delivery, mental health and substance use treatment services, transportation services and housing.
Further, the homeless special needs plan could provide capitated payments to providers who assume the financial risk of providing comprehensive care for homeless individuals — meaning they would face incentives to treat not just a homeless person’s ailments, but the underlying causes of those ailments, including addiction, mental health conditions, and food and housing insecurities.
Start with a Pilot
Because the creation of a homeless special needs plan would require a new approach and face operational challenges, we recommend that the program be pilot tested by the Center for Medicare and Medicaid Innovation (CMMI). CMMI is perfectly suited to measure the outcomes of the pilot according to metrics like total cost of care; quality of health care delivered; management of chronic disease; and, importantly, reductions in rates of homelessness.
None of this is to say that what we propose will be a panacea for our national homelessness epidemic, whose causes are multifaceted and some of which certainly lie outside the realm of health care. Nevertheless, it is also the case that our current, fee-for-service system, fragmented and disjointed as it is, is failing the homeless individuals who live in our neighborhoods. It is also costing us dearly. Addressing Fred’s frostbite through surgery cost the health system exponentially more than finding him a stable and secure place to live.
For Fred and the other half million Americans sleeping on our city’s streets, it’s time to embrace a new approach.